Provider Demographics
NPI:1538167911
Name:LARSON, RUTH A (MD)
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:A
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15525 POMERADO RD
Mailing Address - Street 2:SUITE A2
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2435
Mailing Address - Country:US
Mailing Address - Phone:858-451-3311
Mailing Address - Fax:858-451-1142
Practice Address - Street 1:15525 POMERADO RD
Practice Address - Street 2:SUITE A2
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2435
Practice Address - Country:US
Practice Address - Phone:858-451-3311
Practice Address - Fax:858-451-1142
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41388207ND0101X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G413880Medicaid
CAA48556Medicare UPIN
CAWG41388AMedicare PIN